MEDICARE: PROVIDENCE FOOT AND ANKLE CENTER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP1100X	Podiatric Clinic/Center	E4031	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	CE810Z	OTHER	CA	PTAN

General Provider Information

NPI Number	:	1851522254
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROVIDENCE FOOT AND ANKLE CENTER

Provider Business Mailing Address
First Line	:	1417 STEIN STRAUSS ST
Second Line	:
City	:	FULLERTON
State	:	CA
Zip	:	92833-2159
Country	:	US
Telephone Number	:	714-797-3668
Fax Number	:

Provider Business Practice Location Address
First Line	:	3130 W OLYMPIC BLVD
Second Line	:	SUITE 170
City	:	LOS ANGELES
State	:	CA
Zip	:	90006-2484
Country	:	US
Telephone Number	:	323-732-7551
Fax Number	:	323-732-7829

Authorized Official
Title or Position	:	PODIATRIST/CEO
Name	:	DR. PETER SANG-WOOK PARK
Credential	:	DPM
Telephone Number	:	323-732-7551

Provider Enumeration Date	:	08/03/2009
Last Update Date	:	03/28/2020

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Directions to “PROVIDENCE FOOT AND ANKLE CENTER ” Practice Location

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